12. Prophylaxis for exit site/tunnel infections using mupirocin Date written: February 2003 Final submission: July 2004 Guidelines (Include recommendations based on level I or II evidence) Prophylactic therapy using mupirocin ointment, especially for Staphylococcus aureus carriage intranasally is recommended to decrease the risk of S. aureus catheter exit site/tunnel infections and peritonitis. (Level II evidence) Suggestions for clinical care (Suggestions are based on Level III and IV evidence) The daily use of mupirocin does not appear to lead to significant levels of resistance in the short term (Vas et al 1999), but the levels of resistant organisms isolated become more significant with longer periods (Perez-Fontan et al 2002). After 4 years of continuous use, a significant problem can develop (Annigeri et al 2001). Prophylactic therapy using mupirocin ointment, especially for S. aureus carriage at the exit site is recommended to decrease the risk of S. aureus catheter exit site/tunnel infections and peritonitis (Bernardini et al 1996). Background Catheter exit site/tunnel infections are a major cause of S. aureus peritonitis in peritoneal dialysis (PD) patients. Hence, the prevention of exit site infection (ESI) and tunnel infection due to S. aureus is important. A number of studies have reported that the application of mupirocin ointment nasally or to the catheter exit site prophylactically, reduces S. aureus ESI and peritonitis when compared with historical controls. This guideline is limited to patients with proven nasal carriage.
Search strategy The CARI Guidelines Caring for Australians with Renal Impairment Databases searched: MeSH terms and text words for PD catheters were combined with MeSH terms and text words for tunnel and exit site and then combined with MeSH terms and text words for peritonitis. The search was done in Medline (1966 Week 1 November 2002). The Cochrane Renal Group Register of randomised controlled trials was also searched for trials not indexed in Medline. Date of search/es: 3 December 2002. What is the evidence? Prophylactic intranasal mupirocin treatment: The Mupirocin Study Group (1996) performed a randomised controlled trial (RCT) evaluating 267 PD patients who had been diagnosed as nasal carriers of S. aureus (determined by two positive nasal swabs on two separate occasions). Patients randomised to the intervention group were treated with nasal mupirocin ointment twice daily for 5 consecutive days every 4 weeks. Forty-four episodes of ESI due to S. aureus were reported in the control group compared with 14 in the mupirocin group (p = 0.006). There were no differences in the rates of tunnel infection or peritonitis. There was no evidence of a progressive increase in resistance to mupirocin with time. It was concluded that regular use of nasal mupirocin in PD patients who are nasal carriers of S. aureus significantly reduces the number of ESIs that occur because of this organism. Perez-Fontan et al (1992) ran a randomised trial comparing intranasal mupirocin ointment with neomycin sulphate nasal ointment to treat S. aureus nasal carriers. Retreatment with mupirocin was successful in 66% of cases compared with 20% of those given neomycin. There was a very low incidence of S. aureus peritonitis or catheter-related infections in the patients treated with mupirocin. There is also a trial by Sesso et al (1994) which tested the efficacy of sodium fusidate nasal ointment given twice daily for 5 days against placebo and oral ofloxacin at a dose of 200 mg/day for 5 days. This trial showed no statistically significant difference between sodium fusidate nasal ointment and placebo in the risk of peritonitis, exit site/tunnel infection, catheter removal and all-cause mortality. * * While this study did not use mupirocin, it is a significant randomised prospective trial investigating the prophylactic use of antibiotics for exit site/tunnel infection. Prophylactic topical mupirocin treatment Bernardini et al (1996) conducted a prospective randomised trial, controlling for S. aureus nasal carriage. Eighty-two PD patients were randomised to receive prophylaxis for S. aureus infections using either 600 mg cyclic oral rifampin for 5 days every 3 months or mupirocin ointment 2% applied daily to the exit site. ESI rates were 0.13/year with mupirocin and 0.15/year with rifampin (p = ns). The centre s historical rate was 0.46/year. Rates for peritonitis and catheter loss for both treatment groups were significantly lower than the centre s historical rate of 0.12/year (p < 0.001). Mupirocin ointment at the exit site and cyclic oral rifampin were
considered to be equally effective in reducing ESI, peritonitis and catheter loss due to S. aureus. However, mupirocin ointment at the exit site was inferior to the alternate therapy in this study, particularly in patients who cannot tolerate oral rifampin therapy (12%). Summary of the evidence Two RCTs were found that assessed the use of intranasal mupirocin treatment to prevent ESI, tunnel infection and peritonitis. One study evaluated the benefits of eliminating the nasal carriage of S. aureus with mupirocin ointment compared with placebo, while the other compared mupirocin with neomycin sulphate nasal ointment. There was a statistically significant reduction in the rate of ESIs due to S. aureus in the two studies. One RCT compared topical mupirocin treatment against oral rifampin therapy to prevent ESI, tunnel infection and peritonitis. There was no difference between the groups in the rate of ESI, peritonitis and catheter loss due to S. aureus. Non-randomised studies Davey et al (1999) conducted a cost-effectiveness analysis of the Mupirocin Study Group trial. Overall costs of antibiotic treatment (for all infections combined) were not significantly different (p = 0.2) and total antibiotic costs (including mupirocin) were significantly higher in the mupirocin group (p = 0.01). Casey et al (2000) reported on a prospective, historically-controlled study involving the daily application of mupirocin cream to the catheter exit site of 291 PD patients. Data was collected over an 11-month period and compared with data for all patients from the 11 months prior to the change. There was a 49% relative reduction in the rate of ESI (p < 0.001) and 31% reduction in episodes of peritonitis (p = 0.003) in the mupirocin treatment group. There was also a 68% reduction (p = 0.05) in the rate of S. aureus peritonitis and 37% (p = 0.19) decrease in catheter loss in the mupirocin group. Thodis et al (1998) performed a prospective historically-controlled study of 181 PD patients to evaluate the effectiveness of applying mupirocin ointment to the exit site either daily or three-times-weekly for 1 year. Infection rates found during the study year were compared with the retrospective data. It was reported that the daily application of mupirocin cream significantly reduced the incidence of ESIs due to S. aureus by 91% and reduced peritonitis by 69%. In addition, the overall rate of peritonitis was significantly reduced (p < 0.01). There was no mupirocin resistance 1 year after the institution of local mupirocin use at the catheter exit site to prevent ESI. What do the other guidelines say? Kidney Disease Outcomes Quality Initiative: No recommendation.
British Renal Association: No recommendation. Canadian Society of Nephrology: No recommendation. European Dialysis and Transplant Association European Renal Association: European Guidelines on Best Practice for the Management of Peritoneal Dialysis: 2002 Mupirocin ointment, either intranasal or at the exit site, reduces exit site infections especially in patients who are S. aureus carriers. (Level A) International Society for Peritoneal Dialysis Guidelines/Recommendations: (Keane et al 2000) Prophylactic antibiotic therapy for S. aureus nasal carriage is recommended to decrease the risk of S. aureus catheter exit site/tunnel infections. Implementation and audit 1. Units could perform an audit of their S. aureus infection rate. 2. Mupirocin resistance emergence could be audited at a higher level. Suggestions for future research Perform a long-term study to further investigate the potential for the development of resistance to mupirocin including taking routine swabs to identify and document the presence of resistant organisms.
References The CARI Guidelines Caring for Australians with Renal Impairment Annigeri R, Conly J, Vas S et al. 2001. Emergence of mupirocin-resistant Staphylococcus aureus in chronic peritoneal dialysis patients using mupirocin prophylaxis to prevent exit-site infection. Perit Dial Int 21(6): 554-59. Bernardini J, Piraino B, Holley J et al. 1996. A randomized trial of Staphylococcus aureus prophylaxis in peritoneal dialysis patients: mupirocin calcium ointment 2% applied to the exit site versus cyclic oral rifampin. Am J Kidney Dis 27(5): 695-700. Casey M, Taylor J, Clinard P et al. 2000. Application of mupirocin cream at the catheter exit site reduces exit-site infections and peritonitis in peritoneal dialysis patients. Perit Dial Int 20: 566-68. Davey P, Craig A-M, Hau C et al. 1999. Cost-effectiveness of prophylactic nasal mupirocin in patients undergoing peritoneal dialysis based on a randomized, placebo-controlled trial. J Antimicrob Chemother 43: 105-12. Keane WF, Bailie GR, Boeschoten E et al. 2000. Adult peritoneal dialysis-related peritonitis treatment recommendations: 2000 update. Perit Dial Int 20: 396-411. Perez-Fontan M, Rosales M, Rodriguez-Carmona A et al. 1992. Treatment of Staphylococcus aureus nasal carriers in CAPD with mupirocin. Adv Perit Dial 8: 242-45. Perez-Fontan M, Rosales M, Rodriguez-Carmona A et al. 2002. Mupirocin resistance after long-term use for Staphylococcus aureus colonization in patients undergoing chronic peritoneal dialysis. Am J Kidney Dis 39(2): 337-41. Sesso R, Parisio K, Dalboni A et al. 1994. Effect of sodium fusidate and ofloxacin on Staphylococcus aureus colonization and infection in patients on continuous ambulatory peritoneal dialysis. Clin Nephrol 41(6): 370-76. The Mupirocin Study Group. 1996. Nasal mupirocin prevents Staphylococcus aureus exit-site infection during peritoneal dialysis. J Am Soc Nephrol 7(11): 2403-08. Thodis E, Bhaskaran S, Pasadakis P et al. 1998. Decrease in Staphylococcus aureus exit-site infections and peritonitis in CAPD patients by local application of mupirocin ointment at the catheter exit site. Perit Dial Int 18: 261-70. Vas SI, Conly J, Bargman JM et al. 1999. Resistance to mupirocin: no indication of it to date while using mupirocin ointment for prevention of Staphylococcus aureus exitsite infections in peritoneal dialysis patients. Perit Dial Int 19: 313-14.
Appendix Table 1 Characteristics of randomised controlled trial evidence Study ID (author, year) Bernardini et al 1996 Mupirocin Study Group 1996 Perez Fontan et al 1992 Sesso et al 1994 N Study Design Setting Participants Intervention (experimental group) 82 Randomised controlled clinical trial 267 Randomised controlled clinical trial 22 Randomised controlled clinical trial 22 Randomised controlled clinical trial University Multicentre CAPD patients proven to be S. aureus nasal carriers; 34% diabetic CAPD patients proven to be S. aureus nasal carriers; 20% diabetic Teaching hospital CAPD patients proven to be S. aureus nasal carriers; 26% diabetic Teaching hospital CAPD patients >15 years; 23% diabetic Mupirocin (2%) calcium ointment applied daily to exit site Calcium mupirocin nasal ointment (2%) 2 times/day x 5 days, every 1 month Mupirocin (2%) nasal ointment 3 times/day x 7 days Sodium fusidate (2%) nasal ointment 2 times/day x 5 days, every 1 month Intervention (control group) Rifampin (oral) 300 mg 2 times/day x 5 days, every 3 months Follow up (months) 25 None Placebo ointment 18 None Neomycin sulphate (0.1%) nasal ointment 3 times/day x 7 days 3 None Comments Placebo 7 Trial with 3 arms, including oral ofloxacin 200 mg/day x 5 days versus placebo versus nasal sodium fusidate
Table 2 Quality of randomised trials Study ID (author, year) Method of allocation concealment Blinding Intention-to-treat analysis (participants) (investigators) (outcome assessors) Bernardini et al Unclear No No No Yes 0 1996 Mupirocin Study Unclear Yes Yes No No 0 Group 1996 Perez Fontan et al Unclear No No No No 13.6 1992 Sesso et al 1994 Unclear No No No No 0 Loss to follow up (%)
Table 3 Results for dichotomous outcomes Study ID (author, year) Bernardini et al 1996 Mupirocin Study Group 1996 Outcomes Intervention group (number of patients with events/number of patients exposed) Not estimable (0-61 episodes/dialysis year) Control group (number of patients with events/number of patients not exposed) Not estimable (0-42 episodes/dialysis year) Relative risk (RR) [95% CI] Risk difference (RD) [95% CI] Rate of S. aureus Not estimable Not estimable catheter infection Peritonitis 43/134 44/133 0.97 (0.69 to 1.37) -0.01 (-0.12 to 0.10) Peritonitis rate* 18/1390 19/1236 0.84 (0.44 to 1.60) 0.00 (-0.01 to 0.01) Exit-site/tunnel 26/134 25/133 1.03 (0.63 to 1.69) 0.01 (-0.09 to 0.10) infection Exit-site/tunnel 42/1390 64/1236 0.58 (0.40 to 0.85) -0.02 (-0.04 to -0.01) infection rate* All-cause mortality 22/134 25/133 0.87 (0.52 to 1.47) -0.02 (-0.12 to 0.07) Perez Fontan et al Peritonitis rate* 5/133 4/76 0.71 (0.20 to 2.58) -0.02 (-0.07 to 0.04) 1992 Sesso et al 1994 Peritonitis 1/9 5/13 0.29 (0.04 to 2.07) -0.27 (-0.61 to 0.06) Exit-site/tunnel 5/9 3/13 2.41 (0.76 to 7.62) 0.32 (-0.07 to 0.72) infection Catheter removal 4/9 6/13 0.96 (0.38 to 2.46) -0.02 (-0.44 to 0.41) All-cause mortality 0/9 1/13 0.47 (0.02 to 10.32) -0.17 (-0.40 to 0.07) *Given as episodes/total patient months on PD NA = not available